LAUSR

Dear Editor, For more than 50 years, the Lester Jones tube—a bypass between the conjunctiva and the nasal cavity—is the gold standard for managing epiphora secondary to upper lacrimal outflow obstructions [1]. However, these Pyrex glass tubes are often considered to have tube migration or extrusion in up to 50% of the cases [2]. Recently, the StopLoss Jones tube (SLJT), an innovation in Pyrex glass tubes with an internal silicone flange bonded, was reported to reduce the risk for tube extrusion [3, 4]. Tube insertion requires a bony ostium, which in some cases might preexist due to previous dacryocystorhinostomy (DCR). However, in patients without previous DCR, an external transcutaneous approach is needed for correct tube placement. Herein, we describe—to the best of our knowledge for the first time—a novel transcaruncular diode laserassisted, StopLoss Lester Jones tube procedure without any skin incisions for the treatment of lacrimal canalicular obstructions. Under general anesthesia, a laser fiber optic (300 μm in diameter), connected to an 810-nm wavelength diode laser (Fox; A.R.C.-Laser, Nürnberg, Germany), was fitted into a handpiece and a blunt tear duct cannula, letting 3 mm of the fiber optic stick out at the tip of the cannula (Fig. 1a) [5]. Then, sharp Vannas scissors were used for a 3-mm caruncular incision (Fig. 1b) and gently advancing dissection in inferomedial 30°–45° direction towards the nasal bone. Subsequently, the laser fiber was inserted into the track and carefully pushed towards the bone wall of the lacrimal sac. Positioning of the laser fiber was corrected under visual control using nasal endoscopy (Fig. 1c). Here, the laser’s aiming beam could be visualized and fine adjus tments were made unt i l i t appeared a t the anteroinferior rim of the base of the middle turbinate. Next, laser energy was applied (power 7 to 8 W, pulse duration 200 ms, exposition pause 100 ms). Upon breaching the wall and thus creating the required bony ostium, we enlarged the ostium in a circular manner by vaporizing the margins with further laser spots up to a 2.5 to 3.0 mm in diameter (Fig. 1d). Subsequently, a guide wire with a blunt end (StopLoss-Introducer-Set; FCI, France) was inserted into the track. A 2.8-mm dilatator (FCI, France) was applied to enlarge the passage (Fig. 1e) to an extent, which is later required for safely advancing the 2.1-mm wide tube with its flexible silicon flange. A sizer (FCI, France) was used to measure the distance between the caruncle and nasal mucosa (Fig. 1f). Adding 4 mm to the latter measure results in the adequate tube length. This tube was passed down the guide wire (Fig. 1g) until the silicone flange opened within the nose. After removing the guide wire, the positions of the endonasal silicone flange, nasal opening, and the external flange (Fig. 1h, i) were checked and a suture was passed around the neck of the tube and secured to the caruncular conjunctiva. Our nove l t echn ique of d iode lase r -ass i s t ed , transcaruncular StopLoss Lester Jones tube procedure for the treatment of lacrimal canalicular obstructions has several advantages. No skin incision is necessary and therefore no visible scar must be anticipated. Furthermore, less bleeding can be observed because the related soft and bony tissues are vaporized. In addition, the endonasal silicone flange and the caruncular external flange will help reduce the risk of tube migration or extrusion. In the future, clinical trials are a high priority to follow up larger number of patients. * Ludwig M. Heindl [email protected]